| NPI | 1275971202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: NE 1226) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 1226) |
| 171000000X Military Health Care Provider (Licence: NE 1226) | |
| Enumeration Date | 2013-06-12 |
| Last Update Date | 2023-11-16 |